Impact of the national shortage of polymyxin B in critically ill patients during the COVID-19 pandemic / Impacto da escassez nacional de polimixina B em pacientes gravemente enfermos durante a pandemia de COVID-19 / Impacto del desabasto nacional de polimixina B en pacientes críticos durante la pandemia de COVID-19

Background and Objectives: during the COVID-19 pandemic, the number of critical patients requiring intensive care increased considerably, resulting in an increase in infections due to multi-resistant microorganisms. In Brazil, in 2021, due to the high demand for polymyxin B use, there was a national shortage of the medication. One strategy used to overcome this situation was aminoglycoside use. The work aimed to analyze the impact of replacing polymyxin B with amikacin and gentamicin in the final stage of patients. Method: an analytical study with an observational, cross-sectional design, with a quantitative approach, through a retrospective analysis through the analysis of medical records, with the primary stages being discharges or deaths. Results: mortality was similar between the group treated with aminoglycoside and the group treated with polymyxin B. Within the aminoglycoside group, mortality was higher in the group that had bacteria resistant to the drug than in the group that had infection with an organism sensitive to this drug. Mortality was not affected by comorbidities, age, or number of hospital infections. The main factor that led to the need for dialysis was the combination of two nephrotoxic medications. Conclusion: two hypotheses emerged: the first would be that replacing polymyxin B with aminoglycosides did not impact mortality; the other would be that, regardless of the antibiotic group used, patients had a high risk of death. Despite sample limitations, the study corroborates the adoption of strategies for the rational use of antimicrobials.(AU)

Justificativa e Objetivos: durante a pandemia de COVID-19, o número de pacientes críticos que necessitaram de cuidados intensivos aumentou consideravelmente, resultando em aumento de infecções por microrganismos multirresistentes. No Brasil, em 2021, devido à grande demanda pelo uso da polimixina B, houve escassez nacional do medicamento. Uma estratégia utilizada para superar essa situação foi o uso de aminoglicosídeos. O trabalho teve como objetivo analisar o impacto da substituição da polimixina B por amicacina e gentamicina na fase final dos pacientes. Método: estudo analítico com desenho observacional, transversal, com abordagem quantitativa, por meio de análise retrospectiva por meio de análise de prontuários, sendo as etapas primárias as altas ou óbitos. Resultados: a mortalidade foi semelhante entre o grupo tratado com aminoglicosídeo e o grupo tratado com polimixina B. Dentro do grupo aminoglicosídeo, a mortalidade foi maior no grupo que apresentava bactérias resistentes ao medicamento do que no grupo que apresentava infecção por organismo sensível a este medicamento. medicamento. A mortalidade não foi afetada por comorbidades, idade ou número de infecções hospitalares. O principal fator que levou à necessidade de diálise foi a combinação de dois medicamentos nefrotóxicos. Conclusão: surgiram duas hipóteses: a primeira seria que a substituição da polimixina B por aminoglicosídeos não impactou a mortalidade; a outra seria que, independentemente do grupo de antibióticos utilizado, os pacientes apresentavam alto risco de morte. Apesar das limitações amostrais, o estudo corrobora a adoção de estratégias para o uso racional de antimicrobianos.(AU)

Antecedentes y Objetivos: durante la pandemia de COVID-19, el número de pacientes críticos que requirieron cuidados intensivos aumentó considerablemente, resultando en un aumento de infecciones por microorganismos multirresistentes. En Brasil, en 2021, debido a la alta demanda del uso de polimixina B, hubo escasez nacional del medicamento. Una estrategia utilizada para superar esta situación fue el uso de aminoglucósidos. El trabajo tuvo como objetivo analizar el impacto de la sustitución de la polimixina B por amikacina y gentamicina en la etapa final de los pacientes. Método: estudio analítico con diseño observacional, transversal, con enfoque cuantitativo, mediante un análisis retrospectivo mediante el análisis de historias clínicas, siendo las etapas primarias las altas o defunciones. Resultados: la mortalidad fue similar entre el grupo tratado con aminoglucósido y el grupo tratado con polimixina B. Dentro del grupo de aminoglucósido, la mortalidad fue mayor en el grupo que tenía bacterias resistentes al fármaco que en el grupo que tenía infección con un organismo sensible a este. droga. La mortalidad no se vio afectada por las comorbilidades, la edad o el número de infecciones hospitalarias. El principal factor que llevó a la necesidad de diálisis fue la combinación de dos medicamentos nefrotóxicos. Conclusión: surgieron dos hipótesis: la primera sería que la sustitución de polimixina B por aminoglucósidos no impactó la mortalidad; la otra sería que, independientemente del grupo de antibióticos utilizado, los pacientes tenían un alto riesgo de muerte. A pesar de las limitaciones de la muestra, el estudio corrobora la adopción de estrategias para el uso racional de antimicrobianos.(AU)

Insuficiencia renal aguda en pacientes tratados con aminoglucósidos / Acute kidney injury in patients treated with aminoglycosides

Introducción: El riesgo de desarrollo de insuficiencia renal asociada al uso de aminoglucósidos es muchas veces una limitación para su uso en muchos profesionales de la salud. El objetivo de este trabajo fue conocer la frecuencia de insuficiencia renal en pacientes tratados con aminoglucósidos y los posibles factores asociados a su aparición. Materiales y métodos: Estudio descriptivo, longitudinal y prospectivo. Se incluyeron pacientes que recibieron aminoglucósidos por al menos 72 horas. Se realizó dosaje de creatinina basal y cada 48 horas durante el tratamiento antibiótico y luego de siete días de finalizado el mismo o posterior. Se definió insuficiencia renal aguda como el aumento de creatinina de 0,3 mg/dl con respecto a la basal. Resultados: Se analizaron datos de 107 pacientes y se halló una frecuencia de insuficiencia renal de 10,3%, siendo 5,8% durante el tratamiento aminoglucósido y 4,5% luego de la suspensión del mismo. Los pacientes que desarrollaron insuficiencia renal tenían mayores dosis de aminoglucósidos con respecto al grupo que no presentó dicho evento, siendo esta diferencia estadísticamente significativa. Conclusiones: La frecuencia de insuficiencia renal en pacientes tratados con aminoglucósidos resultó dentro de los intervalos descritos en la literatura y la mayoría de los pacientes presentaron recuperación completa de la función renal. Consideramos que la insuficiencia renal no supone un efecto adverso clínicamente significativo si los aminoglucósidos se usan con las precauciones adecuadas. Esto, sumado a sus buenos resultados clínicos y al bajo impacto en la ecología bacteriana, los convierte hoy en día en antibióticos de uso frecuente en nuestro hospital

The risk of developing renal failure associated with the use of aminoglycosides is often a limitation for its use in many health professionals. The objective of this study was to know the frequency of renal failure in patients treated with aminoglycosides and the possible factors associated with their appearance. Materials and methods: descriptive, longitudinal and prospective study. Patients who received aminoglycosides for at least 72 hours were included. Basal creatinine was measured and every 48 hours during the antibiotic treatment and after 7 days or more of its suspension. Acute renal failure was defined as an increase in creatinine of 0.3 mg/dl compared to baseline. Results: data from 107 patients were analyzed, and the frequency of renal failure was 10.3%, being 5.8% during the treatment with aminoglycoside and 4.5% after its suspension. The patients who developed renal failure had higher doses of aminoglycoside respect to the group that did not present this event, being this difference statistically significant. Conclusions: the frequency of renal failure in patients treated with aminoglycosides was within the ranges described in the literature and the majority of patients had complete recovery of renal function. We believe that renal failure does not represent a clinically significant adverse effect if aminoglycosides are used with adequate precautions. This, added to their good clinical results and low impact on bacterial ecology, makes them very used antibiotics today in our hospital

Effect of polymyxin B-containing regimens on renal function for the treatment of carbapenem-resistant Enterobacteriacea mediastinitis

ABSTRACT A retrospective cohort study, were evaluated: polymyxin B plus aminoglycosides or polymyxin B plus other antibiotics. Any degree of acute kidney injury occurred in 26 (86.6%) patients. The median time to acute kidney injury was 6.0 (95% CI 3-14) days in the polymyxin-aminoglycoside containing regimen group, against 27.0 (95% CI 6-42) days in the polymyxin with other antimicrobial combinations group (p = 0.03). Polymyxin B with aminoglycosides group progressed faster to any degree of renal dysfunction.

Characterisation of plasmid-mediated rmtB-1 in Enterobacteriaceae clinical isolates from São Paulo, Brazil

OBJECTIVES The emergence of 16S rRNA methyltranferases (16 RMTAses) has jeopardised the clinical use of aminoglycosides. RmtB is one of the most frequently reported in Gram-negatives worldwide. In this study, we aimed to estimate the frequency of 16S RMTAses encoding genes in Enterobacteriaceae isolated in a three-month period from a tertiary Brazilian hospital. METHODS All Gram-negatives classified as resistant to amikacin, gentamicin, and tobramycin by agar screening were selected for analysis. The presence of 16SRMTases encoding genes was verified by polymerase chain reaction (PCR). Antimicrobial susceptible profile was determined by broth microdilution. The genetic relationship among these isolates was accessed by pulsed field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). Selected RmtB-producing isolates were characterised by whole genome sequencing (WGS) analysis. RESULTS Twenty-two of 1,052 (2.1%) Enterobacteriaceae were detected as producers of RmtB-1 [Klebsiella pneumoniae (n = 21) and Proteus mirabilis (n = 1)]. blaKPC-2 was identified among 20 RmtB-1-producing K. pneumoniae isolates that exhibited an identical PFGE and MLST (ST258) patterns. Two K. pneumoniae isolates, the A64216 (not harboring bla KPC-2), A64477 (harboring bla KPC-2) and one P. mirabilis isolate (A64421) were selected for WGS. rmtB-1 and bla KPC-2 genes were carried by distinct plasmids. While a plasmid belonging to the IncFIIk group harbored rmtB-1 in K. pneumoniae, this gene was carried by a non-typable plasmid in P. mirabilis. In the three analysed plasmids, rmtB-1 was inserted on a transposon, downstream a Tn2. CONCLUSION Our findings suggested that the rmtB-1 was harbored by plasmids distinct from those previously reported in Bolivia and China. It suggests that multiple mobilization events might have occurred in South America.

Prevalencia de uropatógenos y sensibilidad antimicrobiana en lactantes menores de 2 años provenientes de la comunidad con diagnóstico de infección de vías urinarias / Prevalence of uropathogens and antimicrobial susceptibility in infants younger than 2 years of age from the community with a diagnosis of urinary tract infection

RESUMEN Introducción: la infección urinaria (IU) es una patología frecuente en los niños. La prevalencia de los uropatógenos varía de acuerdo a las regiones geográficas e incluso entre los diferentes centros asistenciales. El conocimiento de dicha prevalencia y de la sensibilidad a los antimicrobianos ayuda a la elección de la antibioticoterapia empírica inicial, permitiendo de esa manera, el control del cuadro agudo y evitando la resistencia bacteriana. Objetivo determinar la sensibilidad de los uropatógenos a los antimicrobianos obtenidos de urocultivos de niños menores de 24 meses con diagnóstico de IU provenientes de la comunidad. Material y métodos: estudio observacional, descriptivo, retrospectivo, de corte transverso. Se analizaron los expedientes clínicos y resultados de urocultivos de lactantes menores de 24 meses internados en el Departamento de Pediatría del Hospital Nacional en el período comprendido entre enero de 2012 a diciembre de 2014 , con diagnóstico de IU. Resultados: los uropatógenos más frecuentemente obtenidos fueron: Escherichia coli (67,6%) seguido de Klebsiella pneumoniae (18,3%), Enterobacter cloacae (8,4%), Pseudomonas aeruginosa (2,8%) y otros en 2,9%. La sensibilidad de la E. coli a la ciprofloxacina, las cefalosporinas y aminoglucósidos fue alta. El 14,6% de Escherichia coli fue productora de betalactamasa de espectro extendido (BLEE). El 100% de las cepas de Klebsiella pneumoniae fuer sensible a amikacina, ciprofloxacina y acidonalidíxico. Conclusiones: el germen más frecuentemente encontrado fue E. coli, seguido de la Klebsiella pneumoniae. El tratamiento de elección recomendado es la combinación de cefalospinas de primera generación asociado a aminoglucósidos, ya que con este esquema se cubrirá más del 95% de los uropatógenos causantes de infección de vías urinarias de la comunidad. Los gérmenes productores de infección urinaria atípica, deberán ser investigados.

ABSTRACT Introduction Urinary tract infection (UTI) is a common pathology in children. The prevalence of uropathogens varies according to geographic regions and even between different care centers. Knowledge of this prevalence and antimicrobial susceptibility helps to choose the initial empirical antibiotic therapy, thus allowing the control of the acute condition and avoiding bacterial resistance. Objective to determine the sensitivity of uropathogens to antimicrobials obtained from urine cultures of children younger than 24 months with diagnosis of UTI from the community. Material and methods: observational, descriptive, retrospective, cross-sectional study. We analyzed the clinical records and results of urine cultures of infants under 24 months admitted to the Department of Pediatrics of the National Hospital in the period between January 2012 and December 2014, diagnosed as UI. Results: the most frequent uropathogen was Escherichia coli (67.6%) followed by Klebsiella pneumoniae (18.3%), Enterobacter cloacae (8.4%), Pseudomonas aeruginosa (2.8%) and others in 2, 9%. The sensitivity of E. coli to ciprofloxacin, cephalosporins and aminoglycosides was high. 14.6% of Escherichia coli was a producers of extended spectrum betalactamase (ESBL). 100% of Klebsiella pneumoniae strains was a sensitive to amikacin, ciprofloxacin and acidonaldehyde. Conclusions: the more frequent germ found was E. coli, followed by Klebsiella pneumoniae. The recommended treatment of choice is the combination of first-generation cephalosporins associated with aminoglycosides, as this scheme will cover more than 95% of the uropathogens that cause urinary tract infection in the community. Germs producing atypical urinary infection should be investigated.

Clostridium difficile: desde el metronidazol al trasplante fecal / Clostridium difficile: from metronidazole to fecal transplant

Clostridium difficile has become one of the main health care-associated infections. During the last decade increase in its incidence, recurrence, colectomy rate and mortality rate has made it necessary to establish the effectiveness of traditional therapies and has motivated the development of new therapies. New antibiotic treatments and alternative therapies have challenged management algorithms, especially in recurrent C. difficile infection. These include the fidaxomicin antibiotic which is selective against C. difficile and fecal microbiota transplantation. This review discussed therapies that are currently in use, their place in management algorithms and provides insight on developing therapies.

Clostridium difficile se ha convertido en una de las principales infecciones asociada a la atención de salud. El aumento en la última década de su incidencia, recurrencia, tasa de colectomía y mortalidad ha hecho necesario establecer la efectividad de las terapias tradicionalmente usadas y ha motivado el desarrollo de nuevas terapias. Nuevos tratamientos antibióticos, así como terapias alternativas a los antibióticos han desafiado los algoritmos de manejo, sobre todo en la infección por C. difficile recurrente. Entre éstos destacan el antibiótico fidaxomicina que es selectivo contra C. difficile y el trasplante de microbiota fecal. En esta revisión se analizan las terapias en uso actualmente, su lugar en los algoritmos de manejo y se dan luces sobre las terapias en desarrollo.

Molecular characterization of multidrug-resistant Klebsiella pneumoniae isolates

Klebsiella pneumoniae is an important cause of healthcare-associated infections worldwide. Selective pressure, the extensive use of antibiotics, and the conjugational transmission of antibiotic resistance genes across bacterial species and genera facilitate the emergence of multidrug-resistant (MDR) K. pneumoniae. Here, we examined the occurrence, phenotypes and genetic features of MDR K. pneumoniae isolated from patients in intensive care units (ICUs) at the First Affiliated Hospital of Xiamen University in Xiamen, China, from January to December 2011. Thirty-eight MDR K. pneumoniae strains were collected. These MDR K. pneumoniae isolates possessed at least seven antibiotic resistance determinants, which contribute to the high-level resistance of these bacteria to aminoglycosides, macrolides, quinolones and β-lactams. Among these isolates, 24 strains were extended-spectrum β-lactamase (ESBL) producers, 2 strains were AmpC producers, and 12 strains were both ESBL and AmpC producers. The 38 MDR isolates also contained class I (28/38) and class II integrons (10/38). All 28 class I-positive isolates contained aacC1, aacC4, orfX, orfX’ and aadA1 genes. β-lactam resistance was conferred through bla_SHV (22/38), bla_TEM (10/38), and bla_CTX-M (7/38). The highly conserved bla_KPC-2 (37/38) and bla_OXA-23(1/38) alleles were responsible for carbapenem resistance, and a gyrAsite mutation (27/38) and the plasmid-mediated qnrB gene (13/38) were responsible for quinolone resistance. Repetitive-sequence-based PCR (REP-PCR) fingerprinting of these MDR strains revealed the presence of five groups and sixteen patterns. ...

Meningitis por Listeria monocytogenes en niñas inmunocompetentes: queso no pasteurizado como probable causa de infección / Listeria monocytogenes meningitis in immunocompetent children: unpasteurized cheese likely cause of infection

Listeria meningoencephalitis is a rare condition, occurring mainly in immunocompromised patients. We present two cases of Listeria monocytogenes meningoencephalitis in immunocompetent children, with successful treatment with betalactam/aminoglycoside combination. Unpasteurized cheese was postulated as the source of infection.

La meningoencefalitis por Listeria spp. es una infección infrecuente, principalmente en pacientes con algún tipo de inmunosupresión. Presentamos dos casos clínicos de meningitis por Listeria monocytogenes en niñas inmunocompetentes con tratamiento exitoso con β lactámicos combinados con aminoglucósidos; se identificó la ingesta de queso no pasteurizado como probable fuente de infección.

Infección por Clostridium difficile: enfrentamiento de la crisis grave y recurrencia / Clostridium difficile infection: management of severe and recurrent disease

Clostridium difficile has become an important healthcare-associated infection due to increased frequency, mortality and recurrence rate. These facts, associated in part to the appearance of epidemic strains have driven changes in diagnostic and therapeutic approaches. The clinical spectrum of C. difficile infection (CDI) ranges from mild diarrhea without systemic compromise to life-threatening pseudomembranous colitis. Metronidazole is the first line treatment in mild CDI; however, the response rate is lower in severe disease, therefore in patients with clinical markers of unfavorable outcome, the first line treatment is oral vancomicin. On the other hand, the increased recurrence rate seen in the last decade with its clinical and economic consequences has forced the development of new therapies that allow change the course of this disease. In this line, the fecal microbiota transplantation and new antibiotics as fidaxomicin has proved to decrease the recurrences.

Clostridium difficile es actualmente una de las principales infecciones asociadas a la atención de salud debido al aumento de su frecuencia, letalidad y capacidad de recurrencia. Estos hechos en parte asociados al surgimiento de cepas conocidas como epidémicas han determinado grandes cambios en el enfrentamiento diagnóstico y terapéutico. El espectro clínico de la infección por C. difficile (ICD) abarca desde una diarrea leve sin compromiso sistémico hasta cuadros de colitis pseudomembranosa que pueden ocasionar la muerte. Metronidazol es el tratamiento de elección de la ICD leve; sin embargo, la tasa de respuesta es inferior en cuadros graves, por lo tanto, en pacientes con marcadores de mal pronóstico vancomicina oral es la terapia de primera elección. Por otro lado, la mayor tasa de recurrencia observada en la última década con sus consecuencias clínicas y económicas ha obligado al desarrollo de nuevas terapias que permitan alterar el curso de la enfermedad. En esta línea, el trasplante de microbiota fecal y nuevos antibióticos como fidaxomicina han mostrado efectividad en reducir las recurrencias.

Antibacterial resistance and trend of urinary tract pathogens to commonly used antibiotics in Kashmir Valley / Resistencia antibacteriana y tendencia de los patógenos de las vías urinarias frente a los antibióticos comúnmente usados en el Valle de Cachemira

OBJECTIVE: Increase in resistance pattern of urinary tract pathogens to conventional antimicrobial agents used for urinary tract infections (UTIs) is gaining the attention of many microbiologists worldwide in respect to treatment of UTIs. The aim of the present study was to obtain data on resistance patterns of pathogens responsible for UTIs to currently used antimicrobial agents in Sher-I-Kashmir Institute of Medical Sciences (tertiary healthcare hospital). METHOD: A total of 2842 samples were collected from both outpatient and inpatient departments. The majority of samples in this study were midstream urine specimens, others included catheterized urine samples. Standard parameters were followed for isolation and identification of clinical isolates and further antimicrobial susceptibility test was done by Kirby Bauer disk diffusion method. RESULTS: Out of 2842 samples, 1980 (67%) were culture positive. Escherichia coli (E coli) was the most prevalent isolate (OP 63%, IP 45.5%) followed by Klebsiella pneumonia (K pneumonia) as the second commonest UTI-causing agent (OP 15.9%, IP 21.7%). High percentage of isolates showed resistance to sulfa drugs such as cotrimoxazole. First generation cephalosporins were ineffective, while aminoglycosides and third generation cephalosporins were effective against E coli, K pneumoniae, Pseudomonas aeruginosa (P aeruginosa), Enterococcus faecalis and Staphyococcus aureus (Staph aureus). Furthermore, this study noticed that glycopeptide drugs such as vancomycin are highly effective against E faecalis and Staph aureus UTIs. CONCLUSION: This study reveals the increased trend in resistance pattern of uropathogens in the valley region. These data may aid health professionals in choosing the appropriate treatment for patients with UTI in the region and hopefully will prevent the misuse of antibiotics.

OBJETIVO: El aumento del patrón de resistencia de los patógenos de las vías urinarias frente a los agentes antimicrobianos convencionales usados para las infecciones de las vías urinarias (IVU) está ganando la atención de muchos microbiólogos a nivel mundial, en relación con el tratamiento de las IVU. El objetivo del presente estudio fue obtener datos sobre los patrones de resistencia de los patógenos responsables de las IVU en el Instituto de Ciencias Médicas Sher-I-Cachemira (hospital de atención terciaria a la salud) frente a los agentes antimicrobianos de uso común. MÉTODO: Se recogieron un total de 2842 muestras provenientes de los departamentos de pacientes externos e internos. La mayoría de las muestras en este estudio fueron especimenes de orina de mitad de micción; otros incluyeron muestras de orina cateterizada. Se siguieron los parámetros estándar para el aislamiento y la identificación de los aislados clínicos, y posteriormente se realizó la prueba de susceptibilidad antimicrobiana mediante el método Kirby-Bauer de difusión por disco. RESULTADOS: De 2842 muestras, 1980 (67%) fueron cultivos positivos. Escherichia coli (E coli) fue el aislado más frecuente (OP 63%, IP 45.5%) seguido por Klebsiella pneumonia (K pneumonia) como el segundo agente más común causante de IVU (OP 15.9%, IP 21.7%). Un alto porcentaje de aislados mostró resistencia a los medicamentos de sulfa, por ejemplo el cotrimoxazole. Las cefalosporinas de primera fueron ineficaces, mientras que los aminoglucósidos y las cefalosporinas de tercera generación fueron efectivas frente a E coli, K pneumoniae, Pseudomonas aeruginosa (P aeruginosa), Enterococcus faecalis y Staphyococcus aureus (Staph aureus). Además, en este estudio se observó que los medicamentos glicopéptidos, tales como la vancomicina, son altamente efectivos frente a las IVU por E faecalis y Staph aureus. CONCLUSIÓN: Este estudio revela un aumento en la tendencia del patrón de resistencia de los uropatógenos en la región del Valle. Estos datos pueden ayudar a los profesionales de la salud a escoger el tratamiento apropiado para los pacientes con IVU en la región, y es de esperar que asimismo ayuden a prevenir el uso inadecuado de antibióticos.

Brucella melitensis: a rarely suspected cause of infections of genitalia and the lower urinary tract

We examined the clinical presentation and outcome of Brucellar infections of genitalia and the lower urinary tract through a review of the medical records of 10 cases of male patients with brucellar infections of the genitalia and lower urinary tract. The mean age of the patients with brucellosis was 49.2, (median 52, range 15-77 years). Eleven out of 17 patients were rural residents, 15 reported that they might have consumed unpasteurized dairy products) and four reported occupational exposure. Symptoms onset was acute in almost all cases. Scrotal pain, epidedimal swelling and fever were the most common symptoms. The Wright test was positive in 13 patients, while Brucella sp. was isolated from blood cultures in six cases. Only two patients were found with abnormal liver ultrasonography. All patients underwent treatment with doxycycline and aminoglycoside for seven days and doxycycline alone for two months. Most of them responded to antibiotic therapy with rapid regression of symptoms. One patient failed to respond to therapy and presented necrotizing orchitis, as well as abscesses, which required orchectomy. Brucellar infections of the genitalia and lower urinary tract have no specific clinical presentation; the usual laboratory examination is not sufficient to diagnose this kind of infection, therefore it could easily be misdiagnosed. An analytical medical history (including overall dietary habits and recent consumption of non-pasteurized dairy products) could indicate Brucelosis as would the persistence of symptoms despite a one-week antibiotic treatment. In general, patients afflicted by brucellar epididymoorchitis respond to Brucellosis antibiotic therapy, except for some rare cases that present necrotizing orchitis and require surgical treatment.

Diagnóstico precoce e tratamento da insuficiência renal crônica em idosos / Early diagnosis and treatment of chronic renal failure in elderly

A insuficiência renal crônica é um problema de saúde pública mundial, afetando todas as idades. Atualmente apresenta prevalência acentuada entre os pacientes idosos. Seu diagnóstico envolve a necessidade de classificação quanto ao estágio em que o paciente se encontra. A avaliação da função renal mais prática inclui as fórmulas de cálculo do ritmo de filtração glomerular (RFG), que são apresentadas no texto. As manifestações da uremia nos idosos são semelhantes àquelas observadas nos segmentos mais jovens. O tratamento conservador visa à correção das mesmas e à manutenção da função renal, com o objetivo de dispensar o tratamento dialítico ou retardar o seu início.

The chronic renal failure constitutes a world wide health problem, affecting all ages, but nowadays with an accentuation of its prevalence among old people. Its diagnosis deserves the needing of a classification of the level of the renal function of the patient. The most practical renal function evaluation includes the equations for the estimation of the glomerular filtration rate which are presented in the text. The uremic manifestations of the aged are the same observed in younger groups and their conservative treatment is in order to promote the corrections of those manifestations and the renal function preservation for preventing the dialysis treatment or its beginning.

Clinical Characteristics and Changing Epidemiology of Clostridium difficile-Associated Disease (CDAD) / 대한소화기학회지

BACKGROUND/AIMS: The spectrum of Clostridium difficile-associated disease (CDAD) ranges from mild diarrhea to life-threatening colitis. Recent studies reported an increase in incidence and severity of CDAD and the presence of severe community-acquired CDAD (CA-CDAD). The aims of this study were to investigate the incidence of CA-CDAD and non-antibiotics-associated CDAD, and to compare the clinical characteristics between hospital-acquired (HA) and CA-CDAD. METHODS: The medical records of 86 patients who were diagnosed as CDAD in Hanyang University Guri Hospital between January 2005 and October 2007 were retrospectively reviewed. RESULTS: Of the 86 patients (mean age 64 years), 53 patients were women. The most frequently prescribed antibiotics were cephalosporins (67.4%), followed by aminoglycosides (38.4%) and quinolones (14%). Of the 86 patients, the average duration of treatment and recovery time of symptoms were 11.5 days and 4.6 days, respectively. Seven percent of patients experienced relapse treatment. The overall incidence rate of CA-CDAD and non-antibiotics-associated CDAD were 10.5% and 22.1%, respectively. CA-CDAD group had lower rate of antimicrobial exposure whilst showing higher rate of complications compared to HA-CDAD group. Three patients in the CA-CDAD progressed towards a severe complicated clinical course, including septic shock. CONCLUSIONS: The incidence rate of CA-CDAD and non-antibiotics-associated CDAD were 10.5% and 22.1%, respectively. CA-CDAD tends to have a higher complication rate compared to HA-CDAD. Community clinicians needs to maintain a high level of suspicion for CDAD, whilst coping with the ever evolving epidemiologic change.

Stenotrophomonas maltophilia, un patógeno nosocomial emergente de importancia creciente / Stenotrophomonas maltophilia: an emergent nosocomial pathogen with an increasing significance

En las últimas décadas se ha estado aislando con frecuencia creciente Stenotrophomonas maltophilia de muestras clínicas, según reporta la literatura mundial. En la provincia de Villa Clara está constituyendo una causa cada vez más relevante de infección intrahospitalaria. El trabajo se propone destacar la importancia del conocimiento médico de este microorganismo, de sus características fundamentales y de las principales propuestas de fármacos para su tratamiento.

In the last decades, Stenotrophomonas maltophilia has been increasingly isolated from clinical samples according to world literature. In Villa Clara province, it is an ever-increasing important cause of intrahospital infection. The aim of this paper was to emphasize the significance of the medical knowledge of this microorganism, its fundamental characteristics, and the main drugs recommended of for its treatment.

Microbial keratitis in Thailand: a survey of common practice patterns.

OBJECTIVE: To describe the current practice patterns and prescription preferences in treating microbial keratitis in Thailand. MATERIAL AND METHOD: A questionnaire was designed and sent to ophthalmologists to describe their practice in patients with microbial keratitis. The questionnaire also presented two case scenarios with microbial keratitis; the less severe in the first patient and the more severe in the second. The recipients were asked about their diagnostic and therapeutic approaches. The surveys were mailed to 300 ophthalmologists around the country. RESULTS: One hundred and forty-three surveys (48.6%) were used in the analysis. Over half the respondents (56%) would do corneal scraping for some patients with suspected microbial keratitis. Smears and cultures of corneal specimens are the most common diagnostic tools (92%) to identify the causative organisms. Of the respondents, 60% would treat Case 1 as an outpatient, compared with 90% would admit Case 2. About half the respondents (47%) would initiate treatment in Case 1 without obtaining scrapings, whereas 79% would prefer microbial work up in Case 2. Monotherapy with topical fluoroquinolone was the most common initial antibiotic prescribed for Case 1 (36%), whereas in Case 2, combined fortified antibiotics (23%) and combined topical antibiotic and topical antifungal (22%) were preferred. For fungal keratitis, topical natamycin and amphotericin B were the most common choices (20% each). CONCLUSIONS: Most Thai ophthalmologists appear to treat patients with suspected microbial keratitis differently, depending on etiology and severity. However, there are some variations in management. The validity of this approach should be established to specify patterns that are most safe and effective.

Current Antimicrobial Usage for the Management of Neutropenic Fever in Korea: A Nationwide Survey

A nationwide questionnaire-based survey was performed to evaluate the current clinical practices for the management of neutropenic fever in hematology units and hematopoietic stem cell transplantation (HSCT) centers throughout Korea. A 86.9% response rate was obtained from a total of 46 doctors and practical policies of the 33 sites were analysed. Approximately 42.4% and 84.8% of the sites responded that they used oral fluoroquinolone as prophylaxis for neutropenic patients receiving chemotherapy and HSCT, respectively. Additionally, 42.4% of the sites responded that they used antifungal prophylaxis in the chemotherapy groups whereas 90.9% of the sites responded that they used antifungal prophylaxis in HSCT recipients. Approximately half of the responding sites prescribed combination regimen with 3rd or 4th cephalosporin plus aminoglycoside as a first-line therapy. Most of the sites considered persistent fever for 2-4 days or aggravated clinical symptoms for 1-2 days as failure of the first-line regimen, and they changed antibiotics to second- line regimens that varied widely among the sites. Twenty-seven sites (84.4%) responded that they considered adding an antifungal agent when fever persisted for 5-7 days despite antibacterial therapy. Amphotericin B deoxycholate was preferred as a first-line antifungal, which was probably due to the limitations of the national health insurance system. The role of oral antibiotics in the management of neutropenic fever still accounted for a small portion. To the best of our knowledge, this survey is the first report to examine the practical policies currently in place for the management of neutropenic fever in Korea and the results of this survey may help to establish a Korean guideline in the future.

Determinación de la susceptibilidad de Escherichia coli en aislamientos del tracto urinario por el sistema DIRAMIC / Antimicrobial susceptibility of Escherichia coli urinary tract isolates by the DIRAMIC system

Las infecciones del tracto urinario (ITU) constituyen una de las más frecuentes en el hospital y la comunidad siendo Escherichia coli el microorganismo principalmente involucrado en estos procesos. El presente trabajo tuvo como objetivo principal evaluar la susceptibilidad de este patógeno frente a un grupo de antimicrobianos comúnmente empleados en el tratamiento de estas infecciones, a partir de un análisis retrospectivo de los datos acumulados y procesados durante el periodo Enero 2001 a Diciembre 2004 por el sistema DIRAMIC desde 11 hospitales pediátricos ubicados en diferentes regiones del país. Se procesaron 3.300 cepas, 2.401 de la comunidad y 899 hospitalarias. Se encontraron porcentajes de resistencia superiores en los aislados de la comunidad siendo significativos (p = 0,00) para kanamicina (37,7% contra 26,0%) cefazolina, (44,7% contra 28,1%) ácido nalidíxico (34,6% contra 24,7%), sulfametoxazol/trimetoprim (84,5% contra 68,8%) y ciprofloxacina (29,2% contra 15,1%), aunque no se observó incremento en el periodo. Para los aislamientos hospitalarios se encontró una tendencia de incremento significativo en el periodo para kanamicina, gentamicina, amicacina, cefazolina y ciprofloxacina (p = 0,00). Los antibióticos menos efectivos in vitro fueron sulfametoxazol/trimetoprim, ampicilina, tetraciclina y cefazolina y los más efectivos quinolonas, nitrofurantoína, gentamicina y amicacina.

Brain abscess due to Scedosporium apiospermum in a non immunocompromised child.

Scedosporium apiospermum is a filamentous fungi that commonly causes cutaneous infection. In certain circumstances, S. apiospermum can also cause invasive disease, which can involve the central nervous system (CNS). When the CNS becomes involved, treatment is difficult, therapeutic options are limited and the prognosis is poor. Early identification and treatment can decrease the mortality rate. Here we present a case of brain abscess with chronic suppurative otitis media, caused by S. apiospermum. This is the first such case report from Nepal. We could identify the organism only post mortem. We could not save the patient, probably due to delay in diagnosis.

Comparative study of three antimicrobial drugs protocol (Ceftriaxone, Gentamicin/Amikacin and Metronidazole) versus two antimicrobial drugs protocol (Ceftriaxone and Metronidazole) in cases of intra-abdominal sepsis.

BACKGROUND: Treatment of intra-abdominal sepsis with antibacterial drugs should be initiated as soon as possible diagnosis is made before surgery and continued in the post operative period, unless required to be changed (when there is no satisfactory clinical response). The ideal agent (s) and duration of therapy remains somewhat controversial. However, early experimental and subsequent clinical studies have indicated that the spectrum of chosen antibacterial activity must encompass both colonic aerobes and anaerobes including B. fragilis. There are a number of multi drug protocols that are used to treat intra-abdominal septic conditions. Empiric use of these protocols not only adds toxicity to already ill patient but therapy becomes costly and utilizes human resource, unnecessarily. AIM OF STUDY: To study the clinical efficacy of the treatment of intra-abdominal sepsis with protocol -A (Ceftriaxone, Metronidazole and aminoglycoside) versus protocol -B. (Ceftriaxone and Metronidazole). MATERIAL AND METHODS: This is a prospective randomized study conducted at NGMC, Nepalgunj, Nepal (2003-2004) on the patient attending for the treatment of intra-abdominal sepsis. Patients included in this study were of inflammation, obstruction with or without gangrene and perforation of appendix, small bowel and large bowel with localized or generalized peritonitis. These patients were managed surgically by- appendicectomy, closure of perforation, resection and anastomosis (R & A) and resection and proximal colostomy. Patients of large bowel obstruction without gangrene and small bowel gangrene were managed by R & A. These patients had significant faecal spillage at the surgical site as well as in the peritoneum. At the end of operation peritoneum and surgical site of all cases were washed with saline and povidone-iodine solution. They were put on one of the two protocols for post-operative treatment. A total 59 patients were included in this study. 32 cases were treated with protocol- A and rest 27 cases were treated with protocol- B. These cases were selected randomly for this study. Their outcome was compiled and compared under following headings: postoperative recovery, postoperative pyrexia, wound infection and dehiscence, anastomotic leak, residual abscess and cost of therapy. STATISTICAL ANALYSIS: Statistical analysis was done with the help of Chi square test. RESULT: Of the 59 patients, 32 were randomized to group I, 27 to group II. These groups were comparable in age, weight, sex and duration of therapy. Uneventful recovery was noted in 87.5 % (28/32) in -group I where as in 70.37% (19 /27) in-group II. Complications were observed in 12.5% in-group I where as 29.63 % in-group II. 10 patients in-group I where as 7 patients in -group II had surgical site infections (SSIs). All of these had superficial wound infection with/or without dehiscence of small portion of wound. A single case of residual abscess and anastomotic leak was observed. Postoperative pyrexia was noted in 8 patients in-group I where as in 6 patients in-group II. In pyrexia, temperature ranged from 99-104 0F. Finally except one case, rest of the cases recovered. On follow up after 3weeks, the cases recovered were doing well. CONCLUSION: At least three conclusions can be drawn from this study. Firstly protocol A is equally effective as protocol B. Secondly; it appears that combining aminoglycoside with Ceftriaxone therapeutically has no significant (P = 0.09) benefit over Ceftriaxone alone. Finally protocol A is less expensive in terms of total therapy than protocol B and can be used without fear even in subnormal functioning kidney.